Nursing Elites

1. A client is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

• A. Reassure the client that this is an expected response to grief.
• B. Ignore the client’s anger and continue with the plan of care.
• C. Tell the client that anger is not going to help his situation.
• D. Encourage the client to express his anger.

Correct answer: A

Rationale: When a client is expressing anger about a diagnosis, it is essential for the nurse to validate the client's feelings. Choice A is correct because reassuring the client that anger is an expected response to grief acknowledges the client's emotions and encourages expression, fostering a therapeutic relationship. This validation helps the client feel understood and supported during a challenging time. Choice B is incorrect as ignoring the client's anger can lead to feelings of neglect and hinder effective communication, which is crucial for providing holistic care. Choice C is inappropriate because telling the client that anger is not helpful dismisses the client's emotions and can further escalate the situation, potentially damaging the nurse-client relationship. Choice D is not the best option as it does not involve acknowledging the client's feelings or providing support and validation, which are vital in promoting emotional well-being and trust between the client and the nurse.

2. A healthcare professional is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 400 mL/hr
• B. 200 mL/hr
• C. 300 mL/hr
• D. 250 mL/hr

Correct answer: A

Rationale: To administer 100 mL over 15 min, the IV pump should be set to deliver 400 mL/hr. This calculation is based on the concept that if 100 mL is given in 15 minutes, to find out how many milliliters are given in an hour, you would multiply by 4 (since 15 minutes is a quarter of an hour). Therefore, 100 mL x 4 = 400 mL per hour. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate required to administer 100 mL over 15 minutes.

3. A client asks a nurse about their Snellen eye test results. The client's visual acuity is 20/30. Which of the following responses should the nurse make?

• A. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”
• B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.”
• C. “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.”
• D. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.”

Correct answer: A

Rationale: The correct answer is A: 'Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.' In the Snellen eye test, a visual acuity of 20/30 means that the client sees at 20 feet what a person with normal vision sees at 30 feet. This indicates that the client's vision is slightly worse than average. Choice B is incorrect as it incorrectly describes the visual acuity of each eye individually, rather than the combined visual acuity. Choice C is incorrect as it misinterprets the meaning of the Snellen eye test results by reversing the values. Choice D is incorrect as it inaccurately describes the visual acuity of the client's eyes, attributing different visual acuities to each eye instead of a combined measurement as indicated by 20/30.

4. A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

• A. Establish consistent boundaries for the toddler.
• B. Place the toddler in a room with the door closed.
• C. Inform the toddler how you feel when he misbehaves.
• D. Use a favorite snack to reward the toddler.

Correct answer: A

Rationale: The correct answer is to establish consistent boundaries for the toddler. This approach helps toddlers understand expectations and promotes consistent behavior. Placing the toddler alone or using food rewards may not effectively teach discipline and could be inappropriate. Informing the toddler about feelings when misbehaving may not be developmentally appropriate for a toddler to understand the consequences of their actions.

5. An 80-year-old client admitted with a diagnosis of a possible cerebral vascular accident has had a blood pressure ranging from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the healthcare provider?

• A. Slurred speech
• B. Incontinence
• C. Muscle weakness
• D. Rapid pulse

Correct answer: A

Rationale: Slurred speech is a classic sign of a worsening stroke, suggesting a potential blockage or hemorrhage affecting speech centers in the brain. Prompt reporting of this symptom to the healthcare provider is crucial for immediate evaluation and intervention. While incontinence (Choice B) is important to monitor, it is not considered an immediate priority over slurred speech in this context. Muscle weakness (Choice C) and rapid pulse (Choice D) are also relevant in stroke assessment, but slurred speech takes precedence due to its strong association with neurological deficits in the setting of a possible cerebral vascular accident.

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